Overview 6/25/2014. Advanced Directives. 2. Out of Hospital DNR/DNI 3. University i Hospital DNR/DNI implementation 4. Special circumstances

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Special circumstances Advanced Directives A written or oral instruction relating to provision of health care

1 Overview 1. Advanced Directives 2. Out of Hospital DNR/DNI 3. University i Hospital DNR/DNI implementation i 4. Special circumstances Advanced Directives A written or oral instruction relating to provision of health care when adult becomes incapacitated. Types of Advance Directives: Healthcare Proxy Consent to DNR order MOLST instructions Living Will Durable Power of Attorney for Medical Decision making (usually from out of state) 1

2 DNR and DNI A DNR order only relates to situation of cardiac or respiratory arrest where CPR will be withheld. A DNI order is a treatment plan item based on an instruction from a patient not to provide mechanical ventilation/intubation should it become medically necessary. BIPAP and CPAP are not considered mechanical ventilation and are not included in a DNI order. University Hospital requires a hospital order for DNI for staff when the treatment plan will not include mechanical ventilation. Scenarios Your 85 year old clinic patient with capacity has asked you to assist her with a DNR/DNI that she may keep at home. Your inpatient for whom you completed an in hospital DNR is now getting discharged, what should you do? 2 Options for Out of Hospital DNR/DNI New York State DOH Nonhospital Order Not to Resuscitate OR New York State DOH Medical Order for Life Sustaining Treatment (MOLST) which also requires the MOLST documentation forms 2

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4 ndex.php/for_professionals/molst/check lists_for_adult_patients 4

IMPORTANT STEP Ask staff to scan document into Upstate

section under demographics EPIC will have a notation in

present on file EPIC will also have a notation in an

5 IMPORTANT STEP Ask staff to scan document into Upstate Records Chartmaxx, EPIC EPIC has an Advanced Directives section under demographics EPIC will have a notation in the outpatient header that an advanced directive is present on file EPIC will also have a notation in an inpatient s header regarding resuscitation status after the order is placed 5

6 AdmittedUpstate Patients 6

7 Scenario 85 year old female arrives to University Hospital with a completed MOLST indicating she does not wish to be resuscitated. She is now being admitted. What should you do. OR You have a patient with capacity wishing to consent to a DNR or DNI and is being admitted 7

ADDITIONAL STEPS Document conversation in the chart. Elements of documentation The DNR/DNI order form was designed to capture all legally required ll documentation.

certain decisions. Place or write an order in the chart Scenario 85 year old unresponsive patient with a significant intracranial hemorrhage.

8 ADDITIONAL STEPS Document conversation in the chart. Elements of documentation The DNR/DNI order form was designed to capture all legally required ll documentation. ti However, it is appropriate to record the discussions resulting in decision making to provide more context to what the provider and patient or surrogate considered and the basis for certain decisions. Place or write an order in the chart Scenario 85 year old unresponsive patient with a significant intracranial hemorrhage. Her husband is present and wishes to consent to a DNR/DNI What are the criteria to allow consent in NY State if the person consenting is not the health care proxy? Relationship of the consenter order of priority given? What part of the document do you complete? 8

Scenario A patient whose resuscitation would be futile which

will die imminently even if treatment is provided and

9 Scenario A patient whose resuscitation would be futile which means would provide no medical benefit because the patient will die imminently even if treatment is provided and providing such resuscitative measures would violate accepted medical standards. No authorized decision makers willing or available Can you make the patient a DNR? Yes 2 physicians needed 9

Scenario It is 2 AM, a patient with a unsurvivable head injury and her spouse wishes to consent to a DNR No attending is present Can the resident complete the DNR?

Parent or guardian but if attending determines minor patient has capacity, the minor must also consent When is a minor emancipated?

10 Scenario It is 2 AM, a patient with a unsurvivable head injury and her spouse wishes to consent to a DNR No attending is present Can the resident complete the DNR? What does the attending have to do? Minors Who may consent? Parent or guardian but if attending determines minor patient has capacity, the minor must also consent When is a minor emancipated? If he or she is the parent of a child or is 16 or 17 years old living independently from parents or guardian. If minor is emancipated, what do you complete? Must have approval from Ethics Review Committee Notification to parents or guardian is required for all DNR orders of minor patients. 10

Special Scenarios Developmentally Disabled

11 Special Scenarios Developmentally Disabled Patients residing in mental hygiene facilities Who is the authorized decision maker? Is there a different form? Do they require additional physician consultation? THESE ARE SPECIAL SCENARIOS CALL SOCIAL WORK IMMEDIATELY FOR HELP 11

12 Remember Discharge patient with appropriate Out of Hospital DNR/DNI 12

Family Health Care Decisions Act (FHCDA)

Family Health Care Decisions Act (FHCDA) Public Health Law Article 29-CC Added by L. 2010, Ch. 8 Applies to general hospitals and residential health care facilities (nursing homes) Went into effect on